New Guidelines Issued for Treatment of Children’s Ear InfectionsAntibiotic Resistance Forces Change in Old Drug Regimen

The throbbing pain, the crying, the sleepless nights — the symptoms of ear infection affect 60 to 70 percent of all children by their first birthdays. Eight out of 10 will have repeat episodes before age 3, and 95 percent of all kids will have at least one ear infection before age 6. Ear infections are the leading cause of pediatric visits, resulting in an estimated 5 million missed school days each year. Rising concerns about antibiotic resistance have sparked doctors to reassess the standard antibiotic treatments most commonly used to fight children’s ear infections. New guidelines for treatment, published in a recent issue of the journal Clinical Pediatrics, take this problem into account. “Because this is the most frequent bacterial infection in children, and there is an increase in antibiotic resistance, we must constantly revisit the question of how to evaluate the various antibiotics used for treatment,” says Alejandro Hoberman M.D., associate professor of pediatrics at the Children’s Hospital of Pittsburgh and co-author of the new recommendations. The recommended guidelines, which are updated from the ones the Centers for Disease Control and Prevention issued a few years ago, identify those at highest risk as: children under the age of 2, children who have taken antibiotics within the last one to three months, and children who attend day care. Day care settings are often breeding grounds for recycled germs. While it may be impossible to avoid day care altogether, doctors recommend keeping your child in smaller groups. Winter and spring seasons yield the highest outbreak of ear infections.

Two kinds of problems Ear inflammation occurs when the middle ear becomes filled with fluid, or infected. It can be caused by bacteria or a virus and is often the result of a common cold or the flu. Young children are more susceptible to ear infections because the Eustachian tube, which connects the middle ear to the back of the throat, is smaller and more horizontal in children than in adults. This makes it is easier for the tube to become blocked, leading to a middle ear that is filled with fluid and cannot drain. There are two types of ear inflammation — acute otitis media (AOM), an infection of the middle ear; and otitis media with effusion (OME), fluid build-up in the ear that can last for several months. Long-term recurrence of OME has been linked to temporary hearing loss and delayed speech and language development. “The distinction between the two inflammations is key to determining treatment,” Dr. Hoberman says. The new guidelines attempt to educate both parents and practitioners about how to differentiate the two conditions. AOM is characterized by a bulging of the tympanic membrane and pus in the ear. “Children with AOM definitely benefit from antibiotic therapy,” Dr. Hoberman says. How to treat them The new recommendations suggest amoxicillin as a first line therapy and high-dose Augmentin for a second line therapy if the amoxicillin fails to work. In severe cases, the committee recommends the use of three injections of Rocephina. “In this age of antibiotic resistance, choosing an antibiotic with a slightly higher bacteriologic success rate translates into a significant number of clinical successes that not only help parents and their sick children feel better, but could also have a tremendous positive impact on public health by reducing treatment failures and unnecessary use of additional antibiotics,” Dr. Hoberman says. The committee which worked on the new guidelines also recommends the pneumococcal vaccine for young children who are prone to ear infections. Studies indicate a slight reduction in the general frequency of AOM, but the vaccine is most effective in children who already have a tendency toward chronic ear inflammations. The flu vaccine may also reduce ear infections since complications from the flu are one of the leading causes of ear infections. Recent studies show the flu vaccine to be more effective in older children, rather than infants. Another treatment the guidelines explore is tympanoscentesis, a simple outpatient procedure that drains the ear of fluid and pus. If your child has fluid in the ear for longer than three months, along with hearing loss and recurrent ear infections that don’t respond to antibiotics, doctors may recommend surgery to insert a small drainage tube into the eardrum. The tube remains in place to keep the ear free of fluids until the eardrum grows. It is eventually pushed out naturally. There continues to be debate in the medical community about whether to administer antibiotics immediately or to postpone usage for a period of watchful waiting. Recent studies in Europe report that 80 percent of ear infections resolved on their own in a week. Dr. Hoberman cautions that countries with reduced use of antibiotics also have significantly higher incidents of infection of the mastoid, the bone behind the ear. He also suggests that many of the cases documented may actually have been OME rather than AOM. OME does not have a high efficacy rate with antibiotic usage. This medical controversy is confusing to parents. Should a parent administer an antibiotic immediately or wait? Experts agree that children under the age of 2 should be treated with appropriate medication immediately. Dr. Jay N. Dolitsky, director of pediatric otolaryngology at the New York Eye and Ear Infirmary, says it depends on the individual case and the symptoms. “If your child is over 2 with no high fever, overwhelming pain or vomiting you might wait a few days before administering an antibiotic.” But he emphasizes the need for parental vigilance and follow-up visits with a doctor to make sure the condition is actually improved.

Oh no! Cod liver oil? Dr. Dolitsky recently took part in a promising new study led by Dr. Linda A. Linday, a pediatrician and researcher at the New York Eye and Ear Infirmary. The study suggests an old-fashioned remedy that might help prevent ear infections: They treated their young patients with lemon-flavored cod liver oil. “With increasing reports of resistant bacteria, parents are looking for alternatives,” Dr. Dolitsky says. “We know that the immune system has an impact on otitis media, so we looked to see if there was something deficient in children’s diets that may improve immune reactions.” The pilot study revealed that children have lower levels of key nutrients. “We compared children and adults and found that children had lower levels of Omega-3 fatty acids, an important anti-inflammatory nutrient, and Vitamin A, the anti-infective vitamin — both of which are found in cod liver oil,” Dr. Linday reports. Children also had lower levels of selenium. Following this discovery, the doctors administered cod liver oil and a multi-vitamin containing selenium to a small number of children suffering from recurrent ear infections. The kids took antibiotics for 12 percent fewer days than before, and many did not experience any additional ear infections for the remainder of the winter season. Dr. Linday says she and his team are currently working on broader studies to establish a connection between these key nutrients and ear infections. “We’re trying to get in early and prevent the chronic inflammation and fluid build-up that comes with ear infection,” Dr. Linday says. “We want to cut down on antibiotic use because we want those antibiotics to work when we really need them.”

Smoke a major player Another major connection was recently drawn between ear infections and secondhand smoke; in one study, recurrent acute otitis media increased by 48 percent in households where either parent smoked. Other studies link allergies to chronic ear infections; allergies can result in congestion that causes fluid to become trapped in the middle ear. “If you suspect your child is suffering from allergies, it’s important to have them properly tested to find out specifically what allergens are affecting them,” Dr. Dolitsky says. With all the new research concerning otitis media, experts encourage parents to consult with their own physicians about the proper course of treatment for their child.

Do Repeat Ear Infections Affect Early Learning? There’s good news for parents who are worried about the long-term effects of ear infections on their kids. A recent study published in the journal Pediatrics found that recurrent ear infections do not necessarily affect early language development and literacy in young children. Joanne Roberts, Ph.D., senior scientist at the Frank Porter Graham Child Development Institute who led the study team at the University of North Carolina, says, “Our data suggests ear infections don’t seem to be making much difference in a child’s development.” The study tracked children from the ages of 6 months to 8 years. Most had a history of recurrent ear infections up to age 4. Children prone to ear infections, particularly otitis media with effusion, develop fluid in the ear that can last for several months. This fluid can reduce sound in the ears, causing temporary hearing loss. Ear infections occur most frequently in infants and toddlers. At this age, children are beginning to develop language and literacy skills. Because language is learned by hearing sounds, any impact on hearing has been hypothesized to have an impact on language development. Dr. Roberts’ study indicated only slightly lower test scores in math and expressive language for younger children with more ear infections. Most of these youngsters caught up with their peers by second grade. “We found a child’s home environment to be extremely important in the development of language and literacy skills,” says Dr. Roberts. “The extent to which parents were sensitive and stimulating was much more important in predicting early learning skills than was the frequency of otitis media.” She encourages early intervention by parents and professionals. Continual language stimulation will help jump-start language learning skills. Dr Roberts recommends parents use simple techniques such as sitting closer to a child while conversing, identifying objects using hand and sight cues, speaking clearly and decreasing distractions during conversations. Read to your child often and explain the pictures. Talk about letters and sounds and what they represent. Remember communication is a two-way street. Listen to your child and praise his speech, even if it is unclear. Creating a positive and rewarding environment for language growth is key to helping your child reach language and learning milestones, Dr. Roberts says. Resources for parents: The New York Eye and Ear Infirmary: Dr. Linda A. Linday: American Speech-Language-Hearing Association (ASHA): or 1-800-638-TALK

By Dawn Hoover

My little guy was not having a good day. In fact, he had been having some pretty crappy days for some time (pun intended). Not yet 2 years old, and he had been suffering with chronic diarrhea for months! His older brother has several food allergies. So, our first thought was to start tracking our youngest’s food intake. I noticed that on the days when I went into the office, leaving him with a sitter, he did not have diarrhea until I returned home and nursed him. Hmmm. We kept a food diary to see if we could find any other connections. Lo and behold, dairy products were definitely making things worse. We immediately switched to soy milk and veggie cheese, and diligently started reading food labels. Things improved, but, not completely. We also tried yogurt and acidophilus, which improved the symptoms, but didn't clear it up completely. I refused to believe that he could have suddenly become lactose-intolerant (though my research online said it could happen). I had nursed him for 18 months with no problems whatsoever! I couldn't shake the feeling (always trust your motherly instincts! They weren't put in your head for nothing!) that his diarrhea had started right about the time he was on antibiotics for a series of ear infections. Though I had brought the problem to the pediatrician's attention, the doctor didn't order any tests until I mentioned the possible antibiotics connection. These tests confirmed clostridium difficile (also called c. diff.). Pediatrician Dr. Dirk Hamp explains: "Clostridium difficile is a bacteria that can cause a condition called Pseudomembranous Colitis. This usually is the result of antibiotic therapy for unrelated conditions such as recurrent or persistent ear infections or other illnesses. While the antibiotics are used to clear up the primary infection, normal germs in the GI tract are eradicated, and clostridium difficile takes over. "It requires a simple lab test to make the correct diagnosis. Fortunately, there are not yet other medications that will help to clear up this secondary illness. Clostridium difficile should be suspected in any child who presents with chronic diarrhea and has a history of antibiotic use for unrelated illnesses." Sadly, my son has now been through two courses of Flagyl (yet another darned antibiotic!) and while it clears it up temporarily, it always returns. I'm afraid that we may have to try some other course of treatment soon. ————————————— C. diff is a bacteria in the intestines. The good (or normal) bacteria ward off the bad (or foreign) bacteria in our bodies. The millions of good bacteria in our systems keep the c. diff under control and in smaller numbers. However, when you take an antibiotic, the levels of good bacteria are reduced and it is possible that the c. diff will overpopulate inside your intestine or colon. Then, two main types of toxins manifest themselves, attacking the intestinal wall. Symptoms may include diarrhea and cramping at first. The later stages are commonly flu-like — weakness, dehydration, fever, nausea, vomiting. It is rare, but death is possible — if the symptoms go untreated. C. diff is usually treatable with antibiotics, and for most people it goes away after a couple of weeks. For the other approximately 20 percent of the patients who are not cured, the common first-line and least expensive drug used is Flagyl (metronidazole). If Flagyl is ineffective, then Vancocin (vancomycin) is commonly prescribed.